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Antisocial personality disorder (APD)

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Antisocial personality disorder (APD) J.J. Deogracias University of Toronto at Mississauga * * * Diagnosis of adult antisocial behaviour (AAB) may be used when ... – PowerPoint PPT presentation

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Title: Antisocial personality disorder (APD)


1
Antisocial personality disorder (APD)
J.J. Deogracias University of Toronto at
Mississauga
2
DSM-IV Criteria for APD
  • Part of the Cluster B (i.e., dramatic/erratic
    cluster) of personality disorders
  • There is a pervasive pattern of disregard for and
    violation of the rights of others occurring since
    age 15 years, as indicated by three (or more) of
    the following
  • failure to conform to social norms with respect
    to lawful behaviors as indicated by repeatedly
    performing acts that are grounds for arrest
  • deceitfulness, as indicated by repeated lying,
    use of aliases, or conning others for personal
    profit or pleasure
  • impulsivity or failure to plan ahead

3
DSM-IV Criteria for APD (contd)
  • irritability and aggressiveness, as indicated by
    repeated physical fights or assaults
  • reckless disregard for safety of self or others
  • consistent irresponsibility, as indicated by
    repeated failure to sustain consistent work
    behaviour or honour financial obligations
  • lack of remorse, as indicated by being
    indifferent to or rationalizing having hurt,
    mistreated, or stolen from another

4
DSM-IV Criteria for APD (contd)
  • The individual is at least 18 years old (under
    18, see Conduct Disorder )
  • There is evidence of Conduct Disorder with onset
    before age 15 years.
  • The occurrence of antisocial behaviour is not
    exclusively during the course of Schizophrenia 
    or a Manic Episode 
  • (APA, 1994)

5
Psychopathy
  • a clinical construct characterized by a cluster
    of interpersonal, affective, and lifestyle
    features, including egocentricity, grandiosity,
    deceptiveness, shallow emotions, lack of empathy,
    guilt, or remorse, impulsivity, irresponsibility,
    and the ready violation of social and legal norms
    and expectations (Hare, 1996, p.25)

6
Psychopathy Checklist Revised (PCL-R)
  • Glibness / Superficial Charm
  • Grandiose Sense of Self Worth
  • Need for Stimulation/Prone to Boredom
  • Pathological Lying
  • Conning/Manipulative
  • Lack of Remorse or Guilt
  • Shallow Affect
  • Callous/Lack of Emotion
  • Parasitic Lifestyle
  • Poor Behavioural Controls

7
PCL-R (contd)
  • Promiscuous Sexual Behaviour
  • Early Behavioural Problems
  • Lack of Realistic, Long-term goals
  • Impulsivity
  • Irresponsibility
  • Failure to Accept Responsibility for Actions
  • Many Short-term Marital Relationships
  • Juvenile Delinquency
  • Revocation of Conditional Release
  • Criminal Versatility

8
Psychopathy in DSM-IV definition
  • Addition note for prison or forensic settings
  • Features common in psychopathy (i.e., lack of
    empathy, inflated self-appraisal and superficial
    charm) may distinguish individuals with APD in
    prison or forensic settings (p. 647).

9
Difference between APD Psychopathy
  • DSM-IV only identifies people with antisocial
    behaviour, who are not necessarily psychopath
  • 20 of people with APD scored high on PCL-R
  • DSM-IV stated that features common in psychopathy
    (i.e., lack of empathy, inflated self-appraisal
    and superficial charm) may distinguish
    individuals with APD in prison or forensic
    settings (p. 647).
  • Person diagnosed with APD outside forensic
    settings may not be diagnosed with APD within
    forensic settings unless they exhibits traits of
    psychopathy
  • For this presentation, terms will be
    interchangeable

10
Epidemiology
  • Prevalence
  • General population 1.0 - 3.5
  • Drug / alcohol abusers 18 - 53
  • Prison inmates 20
  • Gender 3 in men, 1 in women (US)
  • Other interesting statistics
  • responsible for more than 50 of serious crimes
  • 44 of offenders who killed a law enforcement
    officer had APD

11
COMORBIDITY
12
Alcohol and Drug Abuse
  • 80 of individuals with APD abuse drugs
  • Review by Mulder (2002)
  • Cross-sectional alcoholics have high scores on
    measures of impulsivity and novelty seeking, as
    well as high rates of APD
  • Longitudinal studies Antisocial behaviour
    related to later alcoholism, including antisocial
    activity, aggressive and sadistic behaviour, and
    rebellion and hostility
  • Genetic epidemiology In women, the strongest
    association with alcohol dependence was childhood
    conduct disorder in men, this association was
    weaker

13
Major Depression (MD)
  • History of APD predicted fourfold increase in
    probability of reporting a history of MD
  • 38 of total genetic variance in risk of MD was
    associated with APD
  • APD -- major determinant of genetic risk between
    MD and alcohol dependence, and between MD and
    marijuana dependence
  • (Fu et al., 2002)
  • in the absence of anxiety disorders, major
    depression is no longer significantly associated
    with APD
  • (Goodwin Hamilton, 2003)

14
Anxiety Disorders
  • 54.3 of adults with APD met criteria for an
    anxiety disorder during their lifetime
  • any anxiety disorder (especially social phobia
    and PTSD) increases likelihood of APD
  • Anxiety disorder important in the link between
    major depression and APD
  • In the absence of anxiety disorders, major
    depression is no longer significantly associated
    with APD
  • (Goodwin Hamilton, 2003)

15
Attention Deficit Hyperactivity Disorder (ADHD)
  • 21 of hyperactive probands qualified for ASPD, a
    fivefold increase in risk over control group
  • risk for APD among ADHD children is substantially
    influenced by severity of childhood conduct
    problems, and by severity of teen conduct
    disorder (CD)
  • (Fischer et al., 2000)

16
Conduct Disorder (CD)
  • boys with ADHDCD showed a decrease in autonomic
    responses (e.g., skin conductance response)
    compared with ADHD matched children and controls
  • this group showed a pattern similar to that
    reported from studies with psychopathic
    antisocial personalities
  • (Herpertz et al., 2001)

17
NEUROTRANSMITTERS
18
Serotonin (5-HT)
  • mediating impulsive and aggressive behaviours
  • Association between low 5-HT function and
    aggressive behaviour
  • inverse relationship between 5-HT metabolite
    5-hydroxy indoleacetic (5-HIAA) and impulsivity,
    irritability, hostility and aggression
  • tryptophan depletion
  • men with higher basal levels of hostility or
    antisocial traits experience increased hostility
  • patients diagnosed with APD, alcohol dependence,
    or drug dependence
  • chronic ethanol administration decreases 5-HT
    levels, leading to behavioural disinhibition,
    including impulsive aggression
  • antisocial alcoholics with lower basal CSF 5-HIAA
    levels than controls

19
5-HT (contd)
  • Possible genetic connection genes encoding 5-HT
    receptors (especially HTR1B) are likely
    candidates for both substance dependence and APD
  • Inconsistent results

20
Dopamine (DA)
  • Significant associations with D2 D4 receptor
    gene polymorphism and sensation seeking
  • D2 D4 combined contribute more to this
    behaviour than separately
  • May also be related due to comorbid drug abuse
    Abused drugs (e.g., cocaine) release DA in
    nucleus accumbens (NA) and ventral tegmental area
    (VTA) for reinforcement
  • 5-HT plays role by modulating DA activity and its
    effect on neurons of the VTA
  • No empirical data to support this to my knowledge

21
NEUROANATOMY
22
Review by Martens (2001)
  • Neurological dysfunctions, such as brain injuries
    and cerebrovascular disorders
  • Frontal lobe lesions
  • Reduction in prefrontal grey matter volume
  • EEG abnormalities
  • Reduced cortical arousal
  • Frontal-limbic neural circuit (not mentioned in
    review)

23
Frontal Lobe Lesions
  • Orbitofrontal and/or ventromedial frontal cortex
  • implicated in cognitive, linguistic behavioural,
    and affective processes of psychopaths
  • Implicated in aggression and violence
  • acquired sociopathic syndrome following
    ventromedial frontal lobe lesions may contribute
    to poor impulse control in APD
  • activation in posterior orbitofrontal cortex
    during response inhibition (Horn et al., 2003)

24
Prefrontal Cortex
  • MRI people with APD showed significant
    reduction in volume of prefrontal gray matter
  • However, may not be the whole story
  • 13-year-old boy with history of conduct disorder,
    and co-morbid ADHD sustained a self-inflicted
    gunshot wound to medial PFC
  • conduct disorder did not change much after injury
  • No distinct neuropsychological impairment on
    tests thought to be sensitive to frontal function
    after injury

25
Prefrontal-limbic circuit
  • including the amygdala, anterior cingulate, and
    orbitofrontal cortex
  • anticipating aversive stimuli, and mediating
    anticipatory planning emotion regulation
  • Lesions of this circuit result in so-called
    acquired sociopathy
  • Psychopaths show hypoactive frontolimbic
    circuitry during aversive conditioning
  • (Veit et al., 2002)

26
Reduced Cortical Arousal
  • leading to excessive need for stimulation (i.e.,
    sensation seeking)
  • low heart rate associated with aggressive forms
    of antisocial behaviour
  • low heart rate and low skin conductance with
    fearlessness and stimulation sensation seeking
    in antisocial behaviour or APD
  • persons with APD who had prefrontal gray matter
    volume reductions had lower skin conductance
    activity during stressor than those without
    reduced prefrontal gray volume (Raine et al.,
    2000)
  • psychopaths failed to show anticipatory skin
    conductance response in aversive stimuli (Veit et
    al., 2002)

27
PHARMACOTHERAPY
28
Treatment Problems
  • Few treatments, or little research on treatments
    for individuals with APD
  • rarely treated in hospitals because of their
    troublesome behaviours
  • patient trying to manipulate the mental health
    professional or physician (e.g., get doctor to
    prescribe medication they abused in past)
  • APD was found to be negative predictor for
    success of psychotherapy in opiate addicts
  • May attempt to manipulate Will reject medications
    that do not produce euphoria, especially if have
    unpleasant adverse effects

29
Risperidone
  • Antipsychotic -- combined dopamine D2 and
    serotonin 5-HT2 receptor antagonism
  • Placebo-controlled trials of risperidone reported
    significant decreased in aggression in adults
    with dementia in adults with autism, and in
    children with CD
  • Also reported effectiveness against impulsivity
    in borderline personality disorder
  • However, no official study on treating APD

30
Risperidone (contd)
  • Case study for APD
  • 32-year old male fulfilling DSM-IV diagnosis for
    APD
  • major problems severe aggression and impulsive
    violence
  • started on risperidone (6 mg/day)
  • abatement of aggression and impulsivity rapid
    following risperidone 4 days later
  • Side effects antipsychotic-induced akathisia
    (restless and fidgety)
  • lower dosage of risperidone, and adding other
    anti-akathisia agents (biperidon, propranolol and
    diazepam) to control it

31
Quetiapine
  • Atypical antipsychotic agent to treat
    impulsivity, irritability and aggression
  • From four case studies (30-60 day treatment),
  • effective dosage 600 to 800 mg once daily
  • patients attribute treatment compliance to its
    effectiveness and its favourable adverse-effect
    profile
  • successfully used in combination with mood
    stabilizers, particularly gabapentin, in patients
    with affective instability
  • because of treatment cost, it has been
    discontinued leading to reoccurrence of
    aggression and other dangerous manifestations

32
Conclusion
  • Contradictions behind the neurobiology of APD
  • Methodological improvements (i.e., larger sample
    sizes in MRI/fMRI studies)
  • More studies needed
  • Lack of research in pharmacological treatments
  • Only efficacious studies lacked larger sample
    size, control groups, etc.
  • More studies needed
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